Estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa: a systematic review with meta-analysis

Chanie, Ermias Sisay; Moges, Natnael; Baye, Fikadie Dagnew; Mekonnen, Gebrehiwot Berie; Fekadie, Mengistu Melak; Bazezew, Lakachew Yismaw; Anley, Denekew Tenaw; Zemene, Melkamu Aderajew; Gebeyehu, Natnael Atnafu; Adella, Getachew Asmare; Kassie, Gizachew Ambaw; Mengstie, Misganaw Asmamaw; Seid, Mohammed Abdu; Abebe, Endeshaw Chekol; Gesese, Molalegn Mesele; Tegegne, Kirubel Dagnaw; Kebede, Yenealem Solomon; Bantie, Berihun; Feleke, Sefineh Fenta; Dejenie, Tadesse Asmamaw; Bayih, Wubet Alebachew; Kassaw, Amare; Dessie, Anteneh Mengist; Azanaw, Melkalem Mamuye; Chanie, Sewunt Sisay

doi:10.1038/s41598-024-55730-1

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Published: 18 March 2024

Estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa: a systematic review with meta-analysis

Ermias Sisay Chanie¹,
Natnael Moges²,
Fikadie Dagnew Baye¹,
Gebrehiwot Berie Mekonnen¹,
Mengistu Melak Fekadie¹,
Lakachew Yismaw Bazezew²,
Denekew Tenaw Anley³,
Melkamu Aderajew Zemene³,
Natnael Atnafu Gebeyehu⁴,
Getachew Asmare Adella⁵,
Gizachew Ambaw Kassie⁶,
Misganaw Asmamaw Mengstie⁷,
Mohammed Abdu Seid⁸,
Endeshaw Chekol Abebe⁹,
Molalegn Mesele Gesese⁴,
Kirubel Dagnaw Tegegne¹⁰,
Yenealem Solomon Kebede¹¹,
Berihun Bantie¹²,
Sefineh Fenta Feleke¹³,
Tadesse Asmamaw Dejenie¹⁴,
Wubet Alebachew Bayih¹⁵,
Amare Kassaw¹,
Anteneh Mengist Dessie³,
Melkalem Mamuye Azanaw³ &
…
Sewunt Sisay Chanie¹⁶

Scientific Reports volume 14, Article number: 6494 (2024) Cite this article

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Abstract

Malnutrition is more prevalent among children with cerebral palsy and a major factor for child morbidity and mortality in children with different co-morbidity, especially in Sub-Saharan Africa: The main aim of this systematic review and meta-analysis was to estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa. We searched PubMed, Web of Science, Google Scholar, Research Gate, and institutional repositories for papers that reported the proportion of malnutrition among children with cerebral palsy that were published between December 2010 and September 2023. Data were retrieved using the standardized JBI data extraction checklist through Microsoft Excel, and then exported to STATA 17 for further analysis. DerSimonian and Laird’s estimator was used to calculate the pooled effect size in the random-effects model. Statistics such as the Cochran Q test and I2 test were employed to measure heterogeneity. Egger's test and the funnel plot were used to look for publication bias. This systematic review and meta-analysis used 16 studies from Sub-Saharan Africa to estimate the proportion of malnutrition among 2,120 children with cerebral palsy. The pooled proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa by using random-effects model analysis was found to be 59.7% (95% CI; 49.8–69.6). The proportion of malnutrition was also estimated by sample sizes categorized as ≤ 120 and > 120, and the proportion of malnutrition was found to be 54.0 (95% CI: 44.7–63.3) and 64.5 (95% CI: 50.5–78.5). Moreover, the proportion of malnutrition was estimated by accounting for the difference in the year of publication. In this regard, the study classified before ≤ 2017 and > 2017, and the proportion of malnutrition was found to be 53.7 (95% CI: 38.0–69.3) and 62.5 (95% CI: 49.7–75.3) in Sub-Saharan Africa respectively. Malnutrition among children with cerebral in Sub-Saharan Africa was found to be very high. Hence, enhancing and developing strategic guidelines for malnutrition screening, prevention, and nutritional support are crucial among children with cerebral palsy. Furthermore, systematic review, randomized control trials, and qualitative studies are recommended to understand the burden more among children with cerebral palsy in the continent.

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Introduction

Cerebral palsy is a neurological disorder cause a lifelong physical disability¹. With an estimated incidence of 17 million persons globally, cerebral palsy affects around 1 in 500 newborns².

Children with cerebral palsy have a higher risk of developing malnutrition than other children because CP affects the muscles and movements involved in chewing, swallowing, and feeding^3,4. It is a double burden for children with cerebral palsy to develop malnutrition since the problems are worsening each other and add challenges^5,6.

The prevalence of malnutrition among children with cerebral palsy was 7.9–71.46%^5,7, and malnutrition is more prevalent among children with cerebral palsy and a major factor for child morbidity and mortality in children with different co-morbidity, especially in Sub-Saharan Africa⁸.

Children with cerebral palsy are more susceptible to both the long- and short-term effects of malnutrition. Malnutrition lowers quality of life and social engagement, raises susceptibility to illness, and health care utilization, and lowers chances of survival^5,6,9.

Therefore, malnutrition prevention, management, and nutritional support are very crucial and the stakeholders, government, and non-governmental organizations should be included in planning and implementing a package for children with cerebral palsy^5,10,11.

Although some research has been done on the prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa in the past, the combined frequency is not well understood. This systematic review and meta-analysis aimed to determine the pooled prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa. This study may also draw new evidence from different heterogeneity of studies. Hence, this research is of paramount importance in providing evidence to policymakers, researchers, and clinicians to recognize the burden and can help the development of strategic guidelines, and enhance clinical decision-making and monitoring by integrating the recommendations of the study.

Methods

Data sources and search strategies

Review question

The review question of this systematic review and meta-analysis is: What is the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa?

Study selection

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (“PRISMA checklist” was used in the formulation of the systematic review methodology¹². A registration request for the review methodology has been made to the PROSPERO database.

Articles were evaluated based on the inclusion and exclusion criteria from the perspective of the outcome variable (i.e., are they reporting the prevalence or epidemiology of malnutrition among children with cerebral palsy or not).

Search strategy

We searched PubMed, Google Scholar, Web Science, Cochrane databases, and other source that were conducted on malnutrition among children with cerebral palsy, and were published between January 2010 and September 2023. Since research involves constantly testing the hypotheses, staying updated with the latest publications will help us estimate the recent and updated burden of the problem.

The search was conducted using the following keywords: (Prevalence OR proportion OR Burden OR magnitude) AND (Children [MeSH Terms] OR Child OR infant OR Kids) AND (Cerebral palsy [MeSH Terms] OR Disability OR Impairment OR Special needs) AND (Sub-Saharan Africa) OR developing country OR resource-limited setting. The search terms were used separately and in combination using Boolean operators like “OR” or “AND”. The literature search conducted from April 01 to 17, 2023 by authors includes ESC, MAM, MAS, and SSC. All papers published until April 17, 2023, were included in this review.

Eligibility criteria

Inclusion criteria

Language: Articles published in English.
Study area: Only studies conducted in Sub-Saharan Africa were eligible for this study.
Study design: Observational studies (case-control, cohort, and cross-sectional study) that report the prevalence of malnutrition among children with cerebral palsy.
Publication year: Reports made from January 2010 onwards.
Publication condition: Peer-reviewed journal articles as well as articles from the university website.
Outcome of interests: Studies reported the prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa was considered.

Exclusion criteria

Due to the inability to evaluate the quality of publications without access to the complete text and to estimate the outcome variable, articles that were not fully accessed were excluded. Furthermore, studies that did not distinguish between children with cerebral palsy and those with other special needs/disability were excluded from the study.

Outcome measurement among children with cerebral palsy

There is one key outcome variable in this systematic review, which is the prevalence of malnutrition among children with cerebral palsy. The prevalence of malnutrition among children with cerebral palsy was calculated by multiplying the total number of children with cerebral palsy who had malnutrition by 100 and dividing that number by the total number of children with cerebral palsy.

Study selection and data extraction

All Studies reported the prevalence of malnutrition among children with cerebral palsy in Sub-Saharan Africa were transferred to Zotero software, and duplicate articles were removed. The pertinent information, including the names of the authors, the study's design, sample size, study area, and the number of cases/proportions of malnutrition were independently extracted by four authors (ESC, NM, FDB, and GBM). Similar to the preceding step, disagreements were discussed during a consensus meeting with other reviewers (MAM, MAS, ECA, MMG, KDT, SSC, and YSK) for the final decision on which studies to include in the meta-analysis and systematic review.

Quality assessment

We evaluated the included studies' quality using the Joanna Briggs Institute Critical Appraisal instrument for use in JBI Systematic Reviews (JBI-MAStARI)¹³. For the cross-sectional, case–control, and cohort investigations, various items were used in the scale. This systematic review and meta-analysis study included five writers (TAD, WAB, AK, AMD, and MMA) who examined the included articles.

Statistical analysis

The authors verified the accuracy of the retrieved data in a Microsoft Excel sheet before exporting it into STATA 17 for further analysis. The STATA version 17 was used for all analyses in this study.

The degree of heterogeneity was evaluated using Cochrane Q-statistics and an I² statistic with a p-value (< 0.05)^14,15. The test for heterogeneity was high (75%) or moderate (50–74%)¹⁶. Using a random-effects model, the pooled prevalence of malnutrition among children with cerebral palsy was estimated.

Once we had determined that there was moderate or higher heterogeneity, we also looked into the cause of the heterogeneity using subgroup analysis and meta-regression¹⁷. Predetermined subgroups were taken into account for this, including the study sample size, study design, publication year, and study conditions.

The publication bias was estimated through a funnel plot and Egger test¹⁸ and sensitivity analysis was piloted to examine the effect of a single study on the overall estimation.

Results

Search result

We found 1374 studies from PubMed, Google Scholar, Web Science, Cochrane databases, and other source. There were 507 studies were excluded due to duplication. Of the remaining 867 studies, 523 studies were excluded through title and abstract screening. From a total of 344 full-text articles, 328 were excluded due to the outcome variable wasn’t reported. A total of 16 studies were finally included from 09 Sub-Saharan Africa such as Nigeria, Ghana, Uganda, Kenya, Sudan, Cameroon, Tanzania, Botswana, and Zambia (Fig. 1).

Study characteristics and participants

This systematic review and meta-analysis examined 16 studies conducted in Sub-Saharan Africa to determine the prevalence of malnutrition among 2,120 children diagnosed with cerebral palsy. The review included a total of 16 cross-sectional studies with study design^{19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34}.

Out of sixteen studies in this review, five were from Nigeria^{19,21,23,25,26},, three were from Ghana), two studies were from Uganda^22,28, and the remaining seven studies were from Kenya³⁰, Sudan²⁰, Cameroon²⁹, Tanzania³³, Botswana²⁷, and Zambia³¹.

The review found that the highest proportion of malnutrition among children with cerebral palsy was 90%²², while the lowest proportion was 37.3%²³. The sample sizes varied significantly, with the largest study including 388 participants from Nigeria²⁵, and the smallest study including only 16 participants from Zambia³¹ (Table 1).

Table 1 Distribution of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

Full size table

Meta-analysis

The pooled proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa by using random-effects model analysis was found to be 59.7% (95%CI; 49.8–69.6) and showed in (Fig. 2).

Estimation of malnutrition burden by sub group analysis among children with cerebral palsy

The proportion of malnutrition was also estimated by considering the sample size difference. The sample sizes were categorized as ≤ 120 and > 120, and the proportion of malnutrition was found to be 54.0 (95% CI: 44.7–63.3) and 64.5 (95% CI: 50.5–78.5) in Sub-Saharan Africa respectively (Fig. 3). Moreover, the proportion of malnutrition was estimated by accounting for the difference in the year of publication. In this regard, the study classified before ≤ 2017 and > 2017, and the proportion of malnutrition was found to be 53.7 (95% CI: 38.0–69.3) and 62.5 (95% CI: 49.7–75.3) in Sub-Saharan Africa respectively (Fig. 4).

Publication bias

Egger's regression test value showed that there is a statistically significant publication bias in this study (p < 0.044) (Table 2). Besides, a funnel plot showed an asymmetrical distribution which indicated the presence of publication bias (Fig. 5)). Moreover, the results of sensitivity analyses using the random effect model suggested were estimated (Fig. 6).

Table 2 Egger's test of the study of malnutrition among children with cerebral palsy in Sub-Saharan Africa.

Full size table

Discussion

This systematic review and meta-analysis study provides representative data on the estimation of malnutrition among children with CP in Sub-Saharan Africa.

The study suggests that an estimated pooled malnutrition burden among children with cerebral in Sub-Saharan Africa was found to be 57.4% (95% CI; 46.7–68.2).

The finding of this review, the proportion of malnutrition among children with CP is higher than the study conducted in Saudi Arabia¹¹, U.S.A⁷, Argentine¹⁰, Bangladesh³⁵, Nepal³⁶, Turkey³⁷, Vietnam³⁸, and systematic review and meta-analysis Asia 40%³⁹.

This difference might be due to the limited healthcare services, healthcare providers, infrastructure, and limited social support for the optimization of health among children with cerebral palsy by preventing, controlling, and managing malnutrition in Sub-Saharan Africa as compared to other continents^40,41.

Moreover, food insecurity, overpopulation, low educational status, and wars can contribute to malnutrition is too high, particularly in resource-limited settings and vulnerable groups such as children with cerebral play in Sub-Saharan Africa^40,41,42,43.

However, the proportion of malnutrition is lower than in the study conducted in Colombia⁹, and a Systematic Review and Meta-Analysis Arabic speaking countries⁵. This difference might be due to the reference standards cut-off point to diagnosis malnutrition in Colombian and Arabic-speaking countries were included mild, modern, and severe classifications, whereas this study included moderate and severe to declare malnutrition only among children with cerebral palsy^5,9.

The finding of this review will inform the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa for the planners, policymakers, healthcare providers, government and non-governmental organizations, and researchers’ up-to-date data. Additionally, this finding shows the impact of malnutrition in children with cerebral, so prevention and management through the integration of the recommendations to develop guidelines and improve the quality of service is very crucial for children with cerebral palsy in the continent.

The subgroup analysis conducted in this review aimed to estimate the proportion of malnutrition among children with cerebral palsy in various categories within the Sub-Saharan Africa region. One aspect that was examined was the difference in sample sizes, with participants categorized as ≤ 120 and > 120. The estimated proportions of malnutrition were found to be 54.0% (95% CI: 44.7–63.3) and 64.5% (95% CI: 50.5–78.5), respectively. Another factor considered was the variation in the year of publication, with studies classified as published before ≤ 2017 and > 2017. The estimated proportions of malnutrition were found to be 53.7% (95% CI: 38.0–69.3) and 62.5% (95% CI: 49.7–75.3), respectively. Taking into account the significance of a large sample size for accuracy, it is conceivable that the proportion of malnutrition among children with cerebral palsy in Sub-Saharan Africa might be higher than the findings of this study suggest. Moreover, recent studies focusing on this population in the region have shown that, there is an increment in the prevalence of malnutrition among children with cerebral palsy. It is crucial to take these subgroup analysis findings into account to avoid misleading conclusions influenced by confounding factors⁴⁴.

The subgroup analysis findings emphasize the urgent requirement for interventions and targeted strategies to tackle the rising prevalence of malnutrition among children with cerebral palsy.

Limitations of the study

This systematic review and meta-analysis have some limitations. Firstly, the study did not assess the specific causes of malnutrition among children with cerebral palsy. Secondly, only quantitative observational studies published in English were included in the analysis, potentially excluding relevant studies in other languages. Thirdly, studies that did not differentiate between children with cerebral palsy and those with other disabilities were not considered in the analysis.

Conclusion

Malnutrition among children with cerebral in Sub-Saharan Africa was found to be very high. Hence, enhancing and developing strategic guidelines for malnutrition screening, prevention, and nutritional support are crucial among children with cerebral palsy. Furthermore, systematic review, randomized control trials, and qualitative studies are recommended to understand the burden more among children with cerebral palsy in the continent.

Data availability

All data generated or analyzed during this study are included in this published article.

Abbreviations

CP:: Cerebral palsy

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Acknowledgements

We would like to thank all authors of the studies included in this systematic review and meta-analysis.

Author information

Authors and Affiliations

Department of pediatric and child health Nursing, College of Health sciences, Debre Tabor University, Debre Tabor, Ethiopia
Ermias Sisay Chanie, Fikadie Dagnew Baye, Gebrehiwot Berie Mekonnen, Mengistu Melak Fekadie & Amare Kassaw
Department of neonatal health Nursing, College of Health sciences, Debre Tabor University, Debre Tabor, Ethiopia
Natnael Moges & Lakachew Yismaw Bazezew
Department of public health, College of Health sciences, Debre Tabor University, Debre Tabor, Ethiopia
Denekew Tenaw Anley, Melkamu Aderajew Zemene, Anteneh Mengist Dessie & Melkalem Mamuye Azanaw
Department of midwifery, College of medicine and Health science, Wolaita sodo university, Wolaita, Ethiopia
Natnael Atnafu Gebeyehu & Molalegn Mesele Gesese
Department of Reproductive Health and Nutrition, School of Public Health, Woliata Sodo University, Woliata, Ethiopia
Getachew Asmare Adella
Department of Epidemiology and Biostatistics, School of Public Health, Woliata Sodo University, Woliata, Ethiopia
Gizachew Ambaw Kassie
Department of Biochemistry, College of medicine and health sciences, Debre Tabor University, Debre Tabor, Ethiopia
Misganaw Asmamaw Mengstie
Unit of physiology, Department of Biomedical science, college of health science, Debre Tabor University, Debre Tabor, Ethiopia
Mohammed Abdu Seid
Department of Medical Biochemistry, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
Endeshaw Chekol Abebe
Department of comprehensive Nursing, College of Health sciences, Wollo university, Wollo, Ethiopia
Kirubel Dagnaw Tegegne
Department of medical laboratory science, College of health sciences, Debre Tabor University, Debre Tabor, Ethiopia
Yenealem Solomon Kebede
Department of comprehensive Nursing, College of Health sciences, Debre Tabor university, Debre Tabor, Ethiopia
Berihun Bantie
Department of Public Health, College of Health Sciences, Woldia University, Woldia, Ethiopia
Sefineh Fenta Feleke
Department of Medical Biochemistry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
Tadesse Asmamaw Dejenie
Department of Epidemiology and preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia, and Department of Maternal and neonatal health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
Wubet Alebachew Bayih
Department of comprehensive Nursing, College of Health sciences, Debre Berhan university, Debre Berhan, Ethiopia
Sewunt Sisay Chanie

Authors

Ermias Sisay Chanie
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Natnael Moges
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Fikadie Dagnew Baye
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Gebrehiwot Berie Mekonnen
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Mengistu Melak Fekadie
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Lakachew Yismaw Bazezew
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Denekew Tenaw Anley
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Melkamu Aderajew Zemene
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Natnael Atnafu Gebeyehu
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Getachew Asmare Adella
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Gizachew Ambaw Kassie
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Misganaw Asmamaw Mengstie
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Mohammed Abdu Seid
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Endeshaw Chekol Abebe
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Molalegn Mesele Gesese
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Kirubel Dagnaw Tegegne
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Yenealem Solomon Kebede
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Berihun Bantie
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Sefineh Fenta Feleke
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Tadesse Asmamaw Dejenie
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Wubet Alebachew Bayih
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Amare Kassaw
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Anteneh Mengist Dessie
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Melkalem Mamuye Azanaw
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Sewunt Sisay Chanie
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Contributions

E.S.C., N.M., F.D.B., G.B.M., M.M.F., L.Y.B., D.T.A., M.A.Z., N.A.G., G.A.A., G.A.K., M.A.M., M.A.S., E.C.A., and S.S.C. developed the protocol and involved in the design, selection of study, and data extraction. Moreover, E.S.C., M.M.G., K.D.T., Y.S.K., B.B., S.F.F., T.A.D., W.A.B., A.K., A.M.D., and MMA performed the statistical analysis and developed the initial drafts of the manuscript. All authors prepared, read, and approved the final draft of the manuscript.

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Correspondence to Ermias Sisay Chanie.

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Chanie, E.S., Moges, N., Baye, F.D. et al. Estimate the burden of malnutrition among children with cerebral palsy in Sub-Saharan Africa: a systematic review with meta-analysis. Sci Rep 14, 6494 (2024). https://doi.org/10.1038/s41598-024-55730-1

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Received: 20 May 2023
Accepted: 27 February 2024
Published: 18 March 2024
DOI: https://doi.org/10.1038/s41598-024-55730-1

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